Edgerton Care Center, Inc
Edgerton Care Center, Inc in Edgerton, WI — inspection on March 26, 2026.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
interventions put into place after the incident with R1 and R5. CNA E indicated no and explained CNA
have known to add them onto those sheets. CNA E indicated she is to update the cheat sheets every
R1 tootles around the unit independently.
Surveyor asked CNA E if R1 participates in activities. CNA E indicated we try but R1 will not stay in the activities. On 3/18/26 at 11:00 AM, Surveyor interviewed NHA A and asked what the facility's process is for a resident-to-resident altercation. NHA A indicated that staff report the incident to her. NHA A then reports it to the state, investigates it and provides education.
Surveyor asked NHA A if she was aware of an incident between R1 and R5 on 2/16/26.
NHA A indicated she does not recall.
Surveyor asked NHA A if staff had informed her of R1 slapping R5 on 2/16/26. NHA A indicated on 2/16/26 LPN C or ADON at that time did report that R12 witnessed R1 slapping R5.
Surveyor asked NHA A who had reported the incident to the ADON. NHA A could not recall.
Surveyor asked whom R12 reported the incident. NHA A indicated she could not recall.
Surveyor asked if there was any documentation on this incident. NHA A indicated no it was just conversation.
Surveyor asked NHA A if there should be documentation; NHA A indicated yes.
Surveyor asked what NHA A had done with the information she received from staff. NHA A indicated she talked to R12. R12 indicated that R1 did not slap R5. R12 indicated to NHA A that R1 was tapping R5 on the face. NHA A indicated R1 and R5's wheelchairs had somehow hung up together. NHA A indicated there were no words exchanged between R1 and R5. NHA A indicated she had no concerns after talking with R12 about the incident.
Surveyor asked if there was any follow up with R1 and R5 after the conversation with staff and R12. NHA A indicated no.
Surveyor asked if NHA A interviewed the CNA and nurse that had reported it. NHA A indicated no.
Surveyor asked if the facility interviewed other residents to see if there were concerns regarding R1 and their safety in the facility. NHA A indicated no.
Surveyor asked NHA A how it was determined not to investigate this resident-to-resident altercation. NHA A indicated R12 stated R1 lightly tapped R5 on the face.
Surveyor asked NHA A should a resident-to-resident altercation be investigated? NHA A indicated yes.
Surveyor asked NHA A if this incident could have been potentially reportable to state. NHA A indicated yes.
Surveyor asked if there should have been documentation on this incident; NHA A indicated yes.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
During the investigation, Surveyor conducted a review of the facility's grievance file. It was noted that resident R2 submitted a grievance on 3/1/26.
The grievance stated that on 2/27/26, a Certified Nursing Assistant left her wet and did not check and change her per the plan of care.
The facility's investigation included looking over the schedules and the staff member, in question, was new.
The resolution was that the Certified Nursing Assistant was educated regarding check/change of briefs and the importance of peri care.
More training for check-off. It was noted that this grievance was filed against CNA T.
The education provided to CNA T documents that she is new to her occupation of CNA and has been noted to be a phenomenal worker by staff and is always answering call lights and does not complain about doing anything that is asked of her.
Due to the facility not implementing their policy on Abuse/Neglect and Misappropriation of property, they failed to confirm the proper identity of an agency CNA (CNA S) upon hire to work at their facility. CNA S was able to work as CNA T for a total of 12 shifts at the facility, on various units, without proper screening by both the staffing agency and the facility.
Although CNA T was later identified as CNA S, Once the facility became aware that CNA T was really CNA S, they did not change their process to ensure that all employees were properly screened, including verification of identity, prior to working with the residents of the facility.
This had the potential to affect all residents, as the practice remained unchanged and agency staff continued to be used to meet the facility's scheduling demands.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
this online portal. NHA A stated that upon orientation, the facility never asked the agency personnel to
agency and they do all the hiring.
Once the person is hired, they put themselves out on this portal to
had reported this incident to the state survey agency. NHA A stated she did not because it was an active police investigation and she was charged for credit card fraud, not working at the facility under a false identification. NHA A stated the facility continues to use the staffing agency and at this point, no changes had been made to the process when new agency personnel show up for a shift how they verify their identity.
As of exit, the facility was unable to provide additional information as to why they did not report the suspicion of a crime when they became aware that a staffing agency CNA (CNA S) was working under false identification.
Example 3: R6 was admitted to the facility on [DATE].
On 2/21/26, CNA Q (Certified Nursing Assistant) alleged that another staff member had forced R6 out of his bed, despite R6 stating he did not want to get up. In an interview with Surveyors on 3/18/26, CNA Q stated that R6 stated to her in the morning of 2/21/26 that he did not want to get up for breakfast because he was in so much pain and wanted to wait for the nurse to deliver his morning medications before getting out of bed. CNA Q stated that she communicated this to another CNA who then indicated that R6 could not do that and went into R6's room and started yelling at R6 and forced R6 out of bed, while calling him racist. CNA Q stated to Surveyors that she felt this was abusive and reported it to the nurse, who then reported it to NHA A (Nursing Home Administrator).
The facility conducted a thorough investigation into the allegation; however, the State Agency has no record of this being reported.
On 3/18/26 at 10:57 AM, Surveyor interviewed NHA A who stated that she believed the allegation to sound of abuse and NHA A should have reported the incident to the state agency. NHA A stated that by the time she realized that the incident should have been reported to the facility, it was past due and then decided to not report it at all.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
exchanged between R1 and R5. NHA A indicated nothing more was done with the incident or
Surveyor asked if NHA A interviewed the CNA and nurse that had reported it. NHA A indicated no.
and their safety in the facility. NHA A indicated no.
Surveyor asked NHA A how it was determined not to investigate this resident-to-resident altercation. NHA A indicated R12 stated R1 lightly tapped R5 on the face.
Surveyor asked NHA A should a resident-to-resident altercation be investigated? NHA A indicated yes.
Surveyor asked NHA A if this incident could have been potentially reportable to state.
NHA A indicated yes.
Surveyor asked if there should have been documentation on this incident; NHA A indicated yes.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
Administrator) who stated that the facility has had some trouble with their call light system, which is
now fixed.
When asked if each of the 4 CNAs scheduled on each floor should have a device to answer
devices were missing, NHA A indicated she was unaware. NHA A indicated that call lights could possibly go unanswered if CNAs are not properly notified.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
including one that resulted in major injury.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
U did not have an annual performance review.CNA H did not have an annual performance
job performance of each employee shall be reviewed and evaluated at least annually. 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.CNA U was hired 1/28/15. CNA U did not have an annual performance evaluation completed for 2025.CNA H was hired 8/21/19. CNA H did not have an annual performance evaluation completed for 2025.On 3/26/26 at 2:31 PM, Surveyor interviewed CNA H about performance evaluations. CNA H stated I don't recall having one. I have received paperwork about whether or not there was a raise, but no information about my performance.On 3/26/26 at 2:16 PM, Surveyor interviewed HRM W (Human Resources Manager) about performance evaluations. HRM W stated the evaluations for 2025 for CNA U and CNA H had been started by the past DON (Director of Nursing) but were not completed. HRM W stated that an annual evaluation is required.On 3/26/26 at 2:18 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated she would expect staff to have an annual performance evaluation.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
Nursing). DON B stated she started the role at the end of February 2026. DON B expects medications
notify the resident's physician, and notify the resident or responsible party. DON B informed Surveyor
is aware of the medication administration times as an issue and is currently working on fixing the issue. DON B stated the facility has hired more staff and have the Medication Technicians work a longer shift instead of a partial shift.
Surveyor shared the concern with DON B of R2's medications not being given on time resulting in a significant medication error. No further information has been provided by the facility at this time. R2's Carbidopa-Levodopa was not administered per physician orders for at least 32 different administration times as evidence by being administered late.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
shut and secured to prevent pests.This is evidenced by: The facility policy titled, Sanitization, states
contained in dumpsters with lids. On 3/26/26 at 10:25 AM Surveyor observed one lid open on recycling dumpster, and one lid open on regular trash dumpster.On 3/26/26 at 11:10 AM Surveyor interviewed DM V (Dietary Manager).
Surveyor asked DM V if she knew why the dumpster lids would be open. DM V stated that sometimes the wind will catch them or when the truck comes to dump the trash the lid will remain open.
Surveyor asked DM V what days they pick up trash. DM V stated Monday, Wednesday, and Friday for regular trash, and only Fridays for recycling dumpster. DM V stated that her staff tries to remember to shut the lids when the trash is taken out.
Surveyor asked DM V how often her staff takes the trash out. DMV stated that each position in the kitchen is responsible for different stations, trash cans and everything is emptied daily.
Surveyor asked would you expect one of your staff to see the trash lid open and close it, DM V stated yes.
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Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
provide annual training or skills monitoring, per state regulations for two Feeding Assistants.This is
includes, in part: .
Feeding Assistants must receive an annual in-service on relevant feeding assistant topics (any topic area included in the curriculum is appropriate). In addition, Feeding Assistants must be evaluated on a yearly basis to document that their skill performance and feeding competence is satisfactory .Surveyor reviewed DOR K's (Director of Rehabilitation) Feeding Assistant Training Program documents and noted that the facility developed a state approved Feeding Assistant Program and identified DOR K as a Feeding Assistant. DOR K successfully completed training and skills review on 4/17/24 for this program.
Surveyor did not see any annual training for DOR K since completing the program on 4/17/24.Surveyor reviewed [NAME] V's Feeding Assistant Training Program documents and noted that the facility developed a state approved Feeding Assistant Program and identified [NAME] V as a Feeding Assistant. [NAME] V successfully completed training and skills review on 4/17/24 for this program.
Surveyor did not see any annual training for [NAME] V since completing the program on 4/17/24.On 3/26/26 at 11:00 AM, Surveyor interviewed [NAME] V who stated there had been no additional training following completion of the Feeding Assistant Program.On 3/26/26 at 11:31 AM, Surveyor interviewed HR W (Human Resources) about the Feeding Assistant Program. HR W stated that no additional training had been done for feeding assistants as HR W was not aware of the requirement for annual training and skills review for feeding assistants.On 3/26/26 at 1:56 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated she would expect that refresher training would be completed per state regulation.